Attention – Due To Allegations of Plagiarism, This Article Is Highly Suspect 

When the wall came down, everything changed. People who had rarely agreed on anything met halfway, and together set a new paradigm for fighting two of the most devastating scourges the world has ever seen.

On the day they decided to break the wall, though, few realized its significance.

The wall had separated a tuberculosis (TB) clinic and an AIDS clinic in Khayelitsha, a poor township on the outskirts of Cape Town, South Africa. Khayelitsha is home to about a million people. It also has one of the highest burdens of HIV and TB in the world.

Every third pregnant woman in the township is HIV-positive, and the rate of new TB infections is 2,000 for every 100,000 people each year, nearly 20 times the global rate.

For years, Médecins Sans Frontières (MSF, or Doctors Without Borders) staff, who help run AIDS services in the township, had seen the same people lining up one day to receive TB drugs, the next for AIDS medicines, with separate folders and medical files in each clinic. The TB clinic had always been managed by the city and the newer AIDS services by the province.

Over the years, however, it has become increasingly obvious that the two diseases are inseparable and that their treatment too should be managed together. About 70% of TB sufferers in Khayelitsha are HIV-positive, and TB is the leading cause of death in people with HIV.
Power struggle

This disconnect is even more stark in the radically different cultures of the HIV and TB communities.

TB is an old disease and its approach, set primarily by the WHO, is faithful to the principles of classic public health: doing the best for the most people. With the perception that TB was curable, interest in TB research also dried up, and things are done much the same way they were decades ago.

“It’s extremely rigid from case definition to therapeutic guidelines to standard operating procedures, it’s all written in stone and cast,” says Goemaere. “I’ve never seen so many guidelines. It’s almost Stalinian.”

The HIV community, in contrast, driven in part by activists, is focused on empowering the individual, with a heavy emphasis on applying the latest research.

The HIV-TB crisis has resulted in a power struggle between these two cultures, leading up all the way to the WHO’s own TB and HIV programs. “Everyone wonders who’s going to swallow the other,” says Goemaere.

But there are small signs that things are changing, beginning with the WHO’s admission that DOTS, the cornerstone of its TB programs, must take HIV into account (see box, page 269).

The WHO now recommends HIV testing for those infected with TB, preventive TB drugs for HIV-positive people and integration of TB and HIV programs.

In Rwanda and Kenya, 75% of TB sufferers are being tested for HIV, notes Nunn. “That’s up from nothing about a year and a half ago, that’s progress on an enormous scale,” he says. “We have illustrated that it can be done.” The WHO is meeting in March to expand the pilot scheme to more countries.

In South Africa, too, the integrated clinic in Khayelitsha is a resounding success, overflowing with those who are happy to get all their medicines in one place. The integrated programs may also help answer some fundamental questions about TB pathogenesis.

Researchers from the University of Cape Town are collecting samples from those who come to the clinics, studying HIV’s effect on TB progression and perhaps, by extension, what protects people from TB, says Wilkinson. “This is one of the greatest experiments in public health ever invented.”

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